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Below Knee Intervention in Diabetic Foot Ulcer
- Operator: Seung-Whan Lee, MD
Clinical Information

- Relevant clinical history and physical examination:
The patient was 68 years old woman. He have been suffered from long-term (about 37 years) diabetes and lipidemia. About 1 month ago, He injured his right foot at 4th toe in public bathroom. The foot wound have not been improved even proper medical therapy. So, he wanted for further evaluation and proper management. He did not complain any history of intermittent claudication.

- Relevant test results prior to catheterization:
ABI measurement showed 0.78 on Left leg and 0.77 on Right ankle. The three dimensional CT angiogram showed diffuse, total occlusion of the posterior tibial artery and diffuse, tight stenosis on the anterior tibial artery and peroneal artery.

- Relevant catheterization findings:
Severe restenosis of right posterior tibial artery, anterior tibial artery and peroneal artery. The proximal portion of arterial system in right lower limb was relatively healthy. (Figure 1, Figure 2, Figure 3, Figure 4)

Interventional Management

- Procedural step:
After Lt. femoral puncture, The Flexor Tuohy-Borst Silde-Arm Introducer (ansel 7Fr) was inserted. The 0.014 inch Choice-PT guidewire (182cm length) was inserted into Rt.peroneal artery lesion upper site and then balloon angioplasty using coronary balloon (MAVERICK 2.0 x 20) was performed. (Figure 5) but, angiographic result was not satisfactory. As next step, We inserted 0.014 inch Choice-PT wire into posterior tibial artery and then changed into 0.014 inch Floppy wire (300cm length). (Figure 6) The peripheral balloon (SAVVY 3.0 x 100) could not be passed the lesion. Using coronary balloon (AUQA 3.0 x 40 ), stepwise balloon angioplasty was performed in entire lesion. (Figure 7, Figure 8) Angiogram showed some unsatisfactory results in posterior tibial artery. So, using peripheral balloon (SAVVY 3.0 x 100), additional balloon angioplasty was performed in tight lesion. (Figure 9, Figure 10) The final angiogram showed some dissection but good blood flow. (Figure 11, Figure 12, Figure 13)

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